Swimmer’s Ear

Not all ear infections are created equally. Swimmer’s ear differs from a middle ear infection. It is an inflammation of the skin lining the ear canal and is most common in older children and teens. Middle ear infections (otitis media) are caused by pus behind the eardrum and are most common in infants and younger children.

What is swimmer’s ear?

Swimmer’s ear (AKA otitis externa) gets its name because it is commonly caused by water in the ear canal making a good environment for bacteria to grow, causing an infection of the skin.

Water can come from many sources, including lakes, pools, bath tubs, and even sweat, so not only swimmers get swimmer’s ear.

Increasing the risk of swimmer’s ear:

Anything that damages the skin lining the ear canal can predispose to a secondary infection, much like having a scraped knee can lead to an infection of the skin on your knee. Avoid putting anything in your ears, since it can scratch the skin of the ear canal. This includes anything solid to clean wax out of the ear.

Excess earwax can trap water, so cleaning with a safe method can help prevent infection. A little wax is good though — it actually helps prevent bacterial growth. For more on earwax, please see Ear Wax: Good and Bad.

Yes, it sometimes hurts!

Swimmer’s ear can cause intense pain. Sometimes it starts as a mild irritation or itch, but pain worsens if untreated. It typically hurts more if the ear is pulled back or if the little bump at the front of the ear canal is pushed down toward the canal.

Ear buds (for a music player) or hearing aides can be very uncomfortable (and increase the risk of getting swimmer’s ear due to canal irritation).

Other symptoms:

Sometimes there is drainage of clear fluid or pus from the canal.

If the canal swells significantly or if pus fills the canal, hearing will be affected.

More severe cases can cause redness extending to the outer ear, fever, and swollen lymph nodes (glands) in the neck.

Swimmer’s ear can lead to dizziness or ringing in the ear.

Prevention of swimmer’s ear:

Controlling wax

If your child has excessive wax buildup, talk with his doctor about how often to clean the wax. Wax does help keep your ears clean, so you don’t want to clear it too much!

Keep out!

Never put anything solid into the ear canal.

Drying ears

Dry the ear canals when water gets in.

  • Tilt the head so the ear is down and hold a towel at the edge of the canal.
  • Use a hair dryer on a cool setting several inches away from the ear to dry it.
  • If kids get frequent ear infections or are in untreated water (such as a lake), use over the counter ear drops made to help clean the canal. You can buy them at a pharmacy or make them yourself with white vinegar and rubbing alcohol in a 1 to 1 ratio. Put 3-4 drops in each ear after swimming. The acid of the vinegar and the antibacterial properties of the alcohol help to clear bacteria, and the alcohol evaporates to help dry the canal.
  • DO NOT use these drops if there are tubes or a hole in the eardrum, if pus is draining, or if the ear itches or hurts.
Avoiding swimming when needed

If your child has a scratch in the ear or a current swimmer’s ear infection, avoid swimming for 3-5 days to allow the skin to heal.

Avoid bubble baths and other irritating liquids that might get into ear canals.

If there’s tubes…

If your child has tubes placed for recurrent middle ear infections, talk with your ENT about ear protection during swimming.

The use of ear plugs for swimming with tubes has been controversial, but are generally not needed. Dr. Burton discusses this in 5 Fantastical Ear Tube Myths .

Treating swimmer’s ear:

Pain control

If you think your child has swimmer’s ear, start with pain control at home with acetaminophen or ibuprofen per package directions.

Heating pads to the outer ear often help, but do not put any heated liquids into the ear.

Visit your doctor

Most often swimmer’s ear is not an emergency, but symptoms can worsen if not treated with prescription ear drops within a few days.

Bring your child to the office for an exam, diagnosis, and treatment as indicated. Most can go to their usual physician during during normal business hours if you can get adequate pain control at home.

When to be seen immediately

If the pain is severe, redness extends onto the face or behind the ear, the ear protrudes from the head, or there are other concerning symptoms, your child should be seen immediately at their primary care office or another urgent/emergent care setting.

Ear wicks

Occasionally we will remove debris from the canal or insert a wick to help the drops get past the inflamed/swollen canal.

Never attempt this at home unless you’ve been instructed on how to do it safely!

Prescription ear drops and oral medicine

The prescription ear drops may include an antibiotic (to kill the bacteria), a steroid (to decrease inflammation and pain), an acid (to kill bacteria), an antiseptic (to kill the bacteria), or a combination of these.  They are generally used 2-3 times/day.

Have your child lie on his or her side to put the drops in the ear. He or she should remain on that side for several minutes before getting up or changing sides to allow the medicine to stay in the ear. They can use a cotton ball or tissue to collect and dripping when they get up.

Symptoms generally improve after 24 hours and the infection clears within a week.

Oral antibiotics are usually not required unless the infection extends beyond the ear canal.

If an infection causes more itch than pain or does not clear with initial treatment, we might consider a fungal infection. This requires an anti-fungal medication.

No swimming until the infection clears.

Swimming just adds insult to injury. Let the skin heal before getting it soaked in the pool again!

Special circumstances

Kids (and adults) with diabetes or other immune deficiencies are more likely to get severely sick with any infection.

Visit your doctor early if you suspect a problem.

All About Ear Infections – Prevention

Ear infections are all too common and cause a lot of distress for kids and their families. What can we do to help prevent them from happening?

This is part 3 of a three-part series.

  1. All About Ear Infections – What they are and why they happen
  2. All About Ear Infections – Treatments
  3. All About Ear Infections – Prevention

What can be done to prevent ear infections?

Avoid all smoke exposure.

Tobacco smoke is known to predispose children to ear infections, upper respiratory infections and wheezing.

Do not bottle prop.

Keeping a baby’s head elevated a bit while bottle feeding can help prevent ear infections.

Breastfeed.

Breast milk is protective against many types of infection, including ear infections.

General infection prevention.

Avoid taking your infant to places where there are a lot of people during sick season.

Wash hands often. Teach kids to really wash their hands. Because they don’t do a great job much of the time.

Attempt to limit sharing of toys that young children mouth, and wash them between children.

If your child attends daycare, try to find one where there are fewer children per room.

Vaccinate.

One of the biggest causes of bacterial ear infections is pneumococcus. Your child will be vaccinated against this as part of the standard vaccine schedule.

Saline.

If you know me, you know I often recommend saline to the nose.

Saline drops for babies followed by suctioning.

Nasal saline rinses for kids over 2 years of age. (Nasopure has a great library to teach proper use and even videos to get kids used to the idea.)

Saline is a great way to clear the mucus from our nose, which can help prevent cough, sinus infections, and ear infections.

Keep the pacifier in the crib.

When kids play, they often drop their pacifier, which can encourage germs to accumulate on it before they put it back in their mouth.

Xylitol.

There are several studies that suggest chewing gum with xylitol as its sweetener helps prevent ear infections in children who can chew gum. For younger infants, there are nose sprays with xylitol. Xylitol is a naturally occurring substance that is used as a sweetener is many products, many of which are reviewed here. I do not endorse any of these, but do find this a helpful resource.

Treat acid reflux.

This can include dietary changes, positional changes, or medications. Talk to your doctor to see which is right for your child.

Treat allergies.

Treating allergies can help decrease mucus production and improve drainage.

For More Information:

Middle Ear Infections: Summary of the AAP ear infection guidelines
Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age

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All About Ear Infections – Treatments

Yesterday I wrote about what ear infections are, what they’re not, and what causes them. Many parents don’t care so much about the what’s and why’s – they want treatment. Now. Because ear infections hurt, and no one wants to watch their baby suffer. Today I’ll discuss treatments.

This is part 2 of a three-part series.

  1. All About Ear Infections – What they are and why they happen
  2. All About Ear Infections – Treatments
  3. All About Ear Infections – Prevention

Treatments for Ear Infections

First manage the pain

Regardless of the cause of the earache or what the ultimate fix will be, you will want to first manage pain. It does not matter if it’s a real infection or if it’s even the ears that are causing problems, if your child is in pain, treat the pain.

Oral pain relievers

Ear pain can be managed with pain relievers, whether it’s a true infection or simply pain from the congestion that comes with a cold. You can begin pain relief at home whether or not the ear infection is confirmed with standard doses of either acetaminophen or ibuprofen.

Ear drops

Ear drops for pain work fast but the relief doesn’t last long, so I recommend also giving acetaminophen or ibuprofen per standard dosing recommendations in combination with drops. Ear drops can include both over the counter options and prescription options as long as the eardrum doesn’t have a hole or tube in it.

Do not put anything in the ear if you suspect a hole or know your child has a tube unless your doctor recommends it.

Olive oil works pretty well and most of us have that in our kitchen. Saturate a cotton ball with oil (not hot oil) and squeeze the cotton over the ear canal, putting 2-4 drops in the canal.

There are many over the counter ear drops for pain, but I find that the oil you already own is not only cheaper, but works just as well.

Prescription numbing drops are an option if your doctor thinks they are appropriate. These have been difficult to find in recent years for many factors. Be sure you’re using an approved product if you use prescription pain drops.

Positioning

If you’ve had an ear infection as an adult or watched your child refuse to sleep, you’ll know that ear infections can hurt more when lying down. Safely elevating the head can help the pain associated with the increased pressure lying down.

For young infants, elevate the head of the bed by putting risers under the legs of the bed or by wedging something under the mattress. Be sure it is stable, whichever you do. Never put an infant under 1 year of age on a pillow or other soft bedding.

For older children, propping up on several pillows is often helpful. Many toddlers and young children will not stay on pillows, so this is less effective.

Treat associated issues

When kids have ear pain, they often have a runny nose, cough, fever, and other symptoms. Each of these should be managed as discussed on previous blogs: fevergreen snotcoughgenerally sick. How long symptoms will last are discussed here.

treatment varies by age of the child and severity of the infection:

  • Pain relief for anyone with an ear infection is the first treatment. See above.
  • Monitor for the first 2-3 days without antibiotics in many instances, since most ear infections will self-resolve.
  • Antibiotics can be used if symptoms persist more than 2-3 days ~ earlier for children under 6 months of age, those with significant illness, those who had another ear infection within the past 30 days, or for those who have an increased risk of ear infection (such as immune deficiency or an atypical facial structure or chromosomal defect known to affect hearing or immune function).
  • If a child has tubes and develops an ear infection, pus will drain out of the tube. Antibiotic ear drops are the first choice for this type of infection. Antibiotics by mouth are not typically needed.
  • Prevent the next ear infection. See Part 3 tomorrow!

Why not use antibiotics for every ear infection?

Antibiotics don’t treat viruses

The large majority of ear infections are caused by a virus, for which antibiotics are ineffective. About 80% of ear infections self resolve without antibiotics.

Antibiotics can cause problems

Not only are antibiotics not needed, but they also carry risks. About 15% of kids who take antibiotics develop diarrhea or vomiting. Nearly 5% of children have an allergic reaction to antibiotics — this can be life threatening. So when you look at the benefits vs risks, you can see that most of the time antibiotics should not be used as a first treatment.

Superbugs

When bacteria are exposed to an antibiotic but don’t get completely killed, they learn to avoid not being killed the next time they see that same antibiotic. This is called bacterial resistance, also known as “superbugs”.

Superbugs can be shared from one child to another, which explains why some children who have never had antibiotics before have an infection that is not easily taken care of with the first (or second) round of antibiotics and why if a child needed several different antibiotics to clear an ear infection might get better with generic amoxicillin with the next.

It’s the bacteria in the ear that become resistant, not the child. The more we use antibiotics, the more resistance builds up and the less likely antibiotics will work for serious infections.

What are tubes and how do they work?

Tympanostomy tubes are small plastic tubes that are placed in a surgically made hole in the eardrum (tympanic membrane). They keep the hole in the eardrum open so that if pus develops in the middle ear it can drain out through the tube. This helps prevent the pain caused by the pus filling the middle ear area and pushing out on the eardrum. It also helps prevent the hearing loss that happens when the eardrum can’t move due to pus behind it.

photo from USAToday (Rosenfeld RM. A Parent’s Guide to Ear Tubes. Hamilton: BC Decker Inc., 2005)

Pus behind the eardrum causes many symptoms, which may include balance problems, poor school performance, hearing difficulties, behavioral problems, ear discomfort, sleep disturbance, and/or decreased appetite with poor weight gain. The benefits of tube placement for these children must be compared to the cost and risks of anesthesia and having an opening in the eardrum.

The majority of ear infections resolve completely without complication. The longer the pus remains behind the eardrum the less likely it will go away. If the pus is there longer than 3 months, it’s less likely to resolve without treatment.


When are tubes recommended?

Since placing tubes does involve risks, they are not recommended for everyone.
Guidelines recommend the following evaluation for tubes:
  • If pus or fluid has been in the middle ear for over 3 months (OME or OM that never clears), a hearing test should be done.
  • If the hearing test is failed, tubes should be considered.
  • If fluid has been there longer than 3 months but hearing is normal, recheck the hearing every 3-6 months until the fluid clears. If the hearing test is failed on rechecks, then tubes are warranted. (I know plenty of families who opt for tubes despite normal hearing due to quality of life despite this recommendation.)
  • Children with higher risk of speech issues or hearing loss may be considered for tubes earlier. This would include children with abnormal facial structures, such as cleft palate, or certain genetic conditions that predispose to developmental delays, hearing concerns, or immune problems.
 Dr. Deborah Burton is an Ear, Nose, and Throat (ENT) surgeon who answers common ear tube questions and discusses common tube complications in just a couple of her fantastic collection of blogs. She also gives tips on how to avoid ear infections to prevent the need for surgery!

What about recurrent ear infections?

I know parents get frustrated with recurrent ear infections, and I’ve seen many families who are happy that they got tubes for their child after recurrent ear infections, but studies show they aren’t really necessary. If each ear infection clears, that shows that the eustachian tube (the tube that drains the middle ear into the throat) can do its job. As long as the pus is there less than 3 months with each infection, the risk of tubes does not usually outweigh the benefits according to studies.
Again, quality of life can factor in here and I think that’s hard to measure in a study. If kids are missing out on sleep and not eating well due to ear pain, tubes might really help. Discuss this with your child’s doctor.

Are there kids who should be considered tube candidates earlier?

Some kids are more sensitive to the problems associated with OME. These kids might have sensory, physical, cognitive, or behavioral issues that increase his or her risk of speech, language, or learning problems from pus in the middle ear. Children with known craniofacial abnormalities or chromosomal abnormalities who are at higher risk for speech and hearing impairment will also be considered for tubes more liberally. These kids might benefit from tubes even if they don’t have pus for 3 months in the middle ear or hearing loss.

What are complications and risks of tubes?

Tube placement requires anesthesia, which is overall safe, but not without risk.
Tubes keep a hole in the eardrum, which can allow water and bacteria to get into the middle ear, leading to infection. This leads to pus draining out of the ear canal, called otorrhea. This pus can be treated with antibiotic ear drops initially, and oral antibiotics if it last more than a month.

Some ENTs recommend earplugs when kids with tubes swim, but studies do not show that they are needed in most cases. If kids get recurrent otorrhea, they might be candidates for earplugs when swimming. Kids who swim in lake water or do deep water diving might also benefit from earplugs.

NEXT UP: Prevention

So now that you know what ear infections are and how to treat them, check in tomorrow for Part 3: how to prevent them.

For More Information:

Middle Ear Infections: Summary of the AAP ear infection guidelines

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